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<html><head><meta http-equiv="Content-Type" content="text/html; charset=UTF-8"><script type="text/javascript" src="../static/js/zhensuoxx-citypicker.js"></script>
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	 </head><body><div class="g-container" id="g-container-right">
	   <div class="g-main" id="crop-avatar" style="margin:0 auto; width:1024px;">
	   	<form class="form-horizontal" role="form" id="updateForm" onsubmit="return false;" method="post">
	   		<div class="g-msg"><div class="msg-box" id="msg_holder"><span class="n-msg"></span></div></div>
				<div class="my-clinic">&nbsp; 
					<span class="mc-zcrxx"><b></b>诊所信息</span>
					<div class="g-form-button">
	 			 		<button class="btn btn-success button" id="btnSubmit">保存</button> 
	 			 		<div class="btn btn-default button button1" onclick="window.location.href = document.referrer" type="button">取消</div>
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				</div>
				
				<div class="mycc-main clearfix">
					<div class="mycc-photo">					
        				<div id="crop-avatar">
							<div class="avatar-view" data-toggle="tooltip" data-placement="bottom" title="更换诊所logo功能，正在完善中...">
			    				<img id="imgid" src="../static/image/logo-100x100.jpg" alt="Logo">
			    			</div>
						</div>
    					
						<div>诊所图片</div>
					</div>
					<div class="g-form-group">
					   <div class="g-shield">
					    	<label class="g-label-name"><span class="glyph-star">*</span>姓名：</label>
					    	<input type="text" class="g-input g-input-name form-control" data-rule="姓名: required;length(1~64)" data-target="#msg_holder" placeholder="请输入您的姓名" name="xingming" value="17673465583">
						</div> 
						
						<div class="g-shield isHide">
					    	<label class="g-label-name">收货人电话：</label>
					    	<input id="phone" type="text" class="g-input g-input-name form-control" placeholder="请输入手机号码" name="shouhuolxdh" data-target="#msg_holder" value="">
						</div>	
						<!-- <div class="g-shield isHide">
							<div class="g-label-name">验证码：</div>
							<input type="text" class="g-input g-input-name form-control g-change-control" placeholder="请输入验证码" name="yanzhengma"  id="yanzhengm">--%>
							<input  type="button" class="btn  btn-success"  id="g-verification-code" value="获取验证码" ><span class="yanzhengma-msg"></span>--%>
						</div> -->
						<div class="g-shield">
						    <label class="g-label-name"><span class="glyph-star">*</span>诊所名称：</label>
						    <input type="text" class="g-input g-input-name form-control" data-target="#msg_holder" placeholder="请输入诊所名称" name="mingcheng" value="天天">
						 </div>
						<div class="g-shield g-radio-shield">   
						    <label class="g-label-name"><span class="glyph-star">*</span>类型：</label>
							<input type="radio" id="chinese" name="leixing" data-rule="checked" data-target="#msg_holder" value="1">
 								<label name="chinese" id="chinese-label" for="chinese">&nbsp;&nbsp;中西医门诊</label>
 								<input type="radio" id="europe" name="leixing" value="2" checked="checked">
 								<label name="europe" for="europe" id="europe-label" class="radio-label on">&nbsp;&nbsp;中医门诊</label>
 								<input type="radio" id="oral" name="leixing" value="3">
 								<label name="oral" for="oral" id="oral-label">&nbsp;&nbsp;口腔门诊</label>
						 </div>
							 <div class="g-shield">
							    <label class="g-label-name">地址：</label>
								
								    <div class="city-picker ">
								      <!-- 暂无 港澳台 如需要可在city.json文件中添加-->
								      <input type="hidden" class="provinceIn">
								      <input type="text" id="province" class="dropdown-zsxx" name="shengfen" value="湖南省" placeholder="请选择您所在省份">
								　　　　<ul id="provinceUl" class="dropdown-zsxxul dropdown-province"><li id="choosePro" value="-1" style="display:none;"></li></ul>
								    </div>
								    <div class="city-picker ">
								      <input type="hidden" class="cityIn">
								      <input id="citys" name="chengshi" class="dropdown-zsxx" value="岳阳市" placeholder="请选择您所在城市">
								        <ul id="cityUl" class="dropdown-zsxxul dropdown-city"><li id="chooseCity" style="display:none;" value="-1"></li></ul>
								    </div>
								    <div class="city-picker ">
								      <input type="hidden" class="countyIn ">
								      <input id="county" name="quxian" class="dropdown-zsxx" value="岳阳县" placeholder="请选择您所在区/县">
								          <ul id="countyUl" class="dropdown-zsxxul dropdown-county"><li id="chooseCounty" style="display:none;" value="-1"></li></ul>
								    </div>
							</div>
							<div class="g-shield">
							    <label class="g-label-name">详细地址：</label>
							    <input type="text" class="g-input g-input-name form-control" name="dizhi" data-rule="详细地址:length(1~100)" data-target="#msg_holder" placeholder="" value="好地方">

							</div>
							<div class="g-shield">
						    <div class="g-label-name" style="margin-bottom: 15px;">注册日期：</div>
							<span class="g-number"> 2017-06-28 </span>
							</div>
							<div class="g-shield">
								<div class="g-label-name" style="margin-bottom: 15px;">到期日期：</div>
								<span class="g-number">2017-07-28</span>
							</div>
						</div>	
					</div>
				
				
					<div class="ccinfo-main clearfix">
						<div class="mycc-photo"></div>
							<div class="g-form-group "></div>
					</div>
		 	</form>
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		     Loading state
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